The Two Type Transsexual Taxonomy: It’s Time To Provide Different Protocols
In their paper on adolescent age of presentation differences, Arnoldussen et. al., noted,
Because there may be different developmental pathways and/or different ages of declaration of gender incongruence, presumably not everyone will benefit from the same standardized medical treatment, but instead it is important to provide an individualized approach. However, in transgender adolescent care, care is often offered in the form of a protocol. Although protocols allow for some tailored care, the use of protocols does imply that the same general guidance is offered to each adolescent. Gaining more insight into the heterogeneity of adolescents presenting to specialized transgender care services may help to inform clinicians and offer more individualized approaches.
Those “individualized approaches” can still be based on protocols without having to invent any new putative developmental pathway. We have known for decades that the two types of MTF transsexuals have two distinct pathways and life arcs. Until recently, the “late onset” type weren’t seen very often as adolescents (the youngest typically presenting in their early 20’s); now they clearly are, given the much easier access to clinical services and the increased willingness of parents and their primary healthcare providers to refer them to those services. But the clinicians are only now beginning to consider this.
Although ‘ROGD’ has only been recently suggested as a subtype, clinical expert papers on healthcare for transgender adolescents have since long suggested that there are different subgroups within the group of adolescents. Some adolescents with gender incongruence present with a long history of gender nonconformity from early childhood on (pre-pubertal) but other transgender adolescents declare gender incongruence around or after puberty (peri/post-pubertal). It was usually suggested that most adolescents with a request for medical interventions have a history of early childhood-onset gender incongruence and people with late or post-pubertal gender incongruence present themselves to gender services only later in life.
No longer can clinics assume that adolescents presenting at clinics are of the early onset type. With the understanding that adolescents of both types (autogynephilic/autoandrophilic vs. homosexual) and of both natal sexes, are now presenting to clinics in adolescence, with some self selection based on age of presentation (before age 14 and after age 14), it becomes a clinical necessity to properly diagnose adolescents as to which type they belong and to develop and use protocols that fit that type’s needs.
The DSM-5 already provides a framework for the differential diagnoses, if only informally, in their description of early vs. late onset for adolescent & adult gender dysphoria. One thought is to retrospectively differentially diagnose adolescent presenters based upon the formal criteria for gender dysphoria of childhood. A key differentiator is notable gender atypicality as a pre-adolescent. A combination of interviews (of both clients and their parents/primary-caregivers) and of scoring on recalled gender behavior instruments can provide an informed diagnoses. Care should be taken to elicit honest reports on sexual orientation and on autogynephilic/autoandrophilic experiences and desires, as these are also key differentiators.
Recommended Differential Protocols
Because of the difference in sexuality, the “late onset” / AGP / AAP types will have very different later life arcs that present markedly different choices and options for parenting than the “early onset” / HSTS type. Thus, concerns for reproductive preservation will be very different. Early onset transsexuals will seek life partners / spouse of the same natal sex later in life.
For FtM HSTS transsexuals, this means that they will likely have a female partner who can bear children. They will have the option of using a sperm donor. It makes no sense to try to preserve female fertility in an FtM HSTS for both pragmatic and psychological reasons. An HSTS transman will simply NOT desire to carry a child to term while his wife may very likely wish to do so.
For MTF HSTS transsexuals, this means they will very likely have a male partner who will have male fertility. There is no need to preserve male fertility in a MTF HSTS, as she obviously has no need to impregnate a spouse! Further, should she and her husband seek to use the services of a gestational surrogate, her husband can provide the sperm. An MTF HSTS transsexual may also be reticent, even traumatized, by a clinic’s request/demand that she provide a sperm sample, as the mechanics of doing so are anathema. Further, many may present to the clinic before spermatogenesis onset and it would be cruel (and silly) to insist upon them waiting until that event as it would entail unwanted masculinization to no purpose.
The issue of fertility preservation in “late onset” transsexuals of both sexes is quite different.
In the one sex, simply retaining female internal reproductive organs is enough. Already, quite a few androphilic FtMs have elected to stop HRT treatments long enough to get pregnant. Being a “pregnant man” presents no psychological difficulties for them.
For AGP MTF transsexuals, there is a very clear need for clinical intervention early in the process, before any puberty blocking or HRT is begun, but most especially before any genital surgery is performed. Fortunately, such “late onset” adolescents are also very likely to be “late presenting” and thus already to have experienced spermatogenesis onset. Transsexuals of this type typically have no psychological reservations about providing sperm samples for cryo-storage.
Psychological / Psychiatric support needs of the two types are very different. It is well documented that the “late onset” type have higher comorbid psychological difficulties, including “late presenting adolescents”. Further, there is documentation that while the late onset type welcome therapeutic support and found them useful during their transition, early onset transsexuals do not; They neither need them nor want them. They especially do not have good experiences in mixed groups of the two types.
Evaluation for medical transition services should pay particular attention to the “late onset” type in both natal sexes, but especially in natal females as they have shown to be more likely to experience regret, however rare over all. Such regret and detransitioning in “early onset” is rare to non-existent. Clinicians should be especially wary of those teens who are falsely claiming to be “trans” or “non-binary” with no real indications of gender dysphoria.
Overall, it is long past time that differential diagnoses and separate protocols of youth referred to clinics be implemented.
Further Reading:
A Deeper Dive: Transsexual Teens Are A Heterogeneous Group
American Psychiatric Association Supports The Two Type Transsexual Taxonomy
Information For Healthcare Providers
Essay on why the two types should be differentially diagnosed and treated
Insights Gleaned From Detrans People
Falsely Claiming to be “trans” is cool (NOT!)
Further External Reading:
Treatment Recommendations for HSTS Transkids
References:
Arnoldussen, M., de Rooy, F. B. B., de Vries, A. L. C., van der Miesen, A. I. R., Popma, A., & Steensma, T. D. (2023). Demographics and gender-related measures in younger and older adolescents presenting to a gender service. European Child and Adolescent Psychiatry, 32, 2537–2546. https://doi.org/10.1007/s00787-022-02082-8
de Rooy, F.B.B., Arnoldussen, M., van der Miesen, A.I.R. et al. Mental Health Evaluation of Younger and Older Adolescents Referred to the Center of Expertise on Gender Dysphoria in Amsterdam, The Netherlands. Arch Sex Behav (2024). https://doi.org/10.1007/s10508-024-02940-3
Sorbara, J. C., Chiniara, L. N., Thompson, S., & Palmert, M. R. (2020). Mental health and timing of gender-affirming care. Pediatrics, 146. https://doi.org/10.1542/peds.2019-3600
Sorbara, J. C., Ngo, H. L., & Palmert, M. R. (2021). Factors associated with age of presentation to gender-affirming medical care. Pediatrics, 145. https://doi.org/10.1542/peds.2020-026674
Low Fertility Preservation Utilization Among Transgender Youth Nahata, Leena et al.Journal of Adolescent Health, Volume 61, Issue 1, 40 – 44 DOI: 10.1016/j.jadohealth.2016.12.012
Know Your Enemy: “Do No Harm”
While the usual suspects of right wing homophobic and transphobic organizations have been lobbying against transsexual rights and access to medical care, the new villain is an organization falsely and ironically called “Do No Harm”.
Further External Reading:
https://www.politico.com/news/2024/07/21/conservative-kidney-doctor-trans-kids-care-00166641
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Lavender Marriage
In the very late 1970s, I knew a couple of siblings who like me were in their college years and were very supportive of LGBT people. They shared a family secret with me, showing me a family photo album and telling me about their “Aunt Bob & Uncle Jane”. There was a photo of an obviously swishy gay man draped on a couch and a butch lesbian standing closer to the camera, holding a purse by its shoulder strap in her fist, away from her body, as though holding a dead animal by its tail, not wishing it to touch her body. Another photo was of their foster/adopted son, then about ten years old.
Their history is very much an indictment of mid-20th Century homophobia. Bob, their maternal uncle, had been arrested and charged as a younger man with receiving and possessing homosexual pornography in the mail. Today, no one would have batted an eye, as it was soft core. But in the 1960s, things were very different in the United States. This would have ruined his career as he was an elementary school teacher. His family literally bribed the prosecutor to drop the charges and expunge the records. But the rumors were likely to remain and that would be enough. So, like many gay people in those days, he entered a “Lavender Marriage” with a butch lesbian, who was also a school teacher. This served to allow both to pretend to be a heterosexual couple. Later, they adopted a boy from the foster care system.
Their story brought to mind a “case study” in one of my mother’s college text books on psychology that I had read. Starting at the age of 13, I began reading my parents university textbooks, cover to cover. My mother’s psychology texts were my first and favorite. I wish I could recall the name of the textbook with the case study, so that I could properly cite it here, today, but a bit over five decades have passed since then.
The case study dealt with the story of a young woman taking a new job working in a business office. The author(s) tell how the girlfriends of her male co-workers were jealous of her until actually meeting her, upon which all their concerns evaporated. The story then goes into greater detail about how “mannish” she was, how none of the men found her attractive. The case study concludes with the author(s) expert opinion that this young woman would never be happy romantically until she met and married a man who was as “effeminate” as she was masculine, making the explicit pronunciation that gender complimentary attraction was available and necessary, but only if it was between a man and a woman.
To this day, looking back, I still don’t know if the authors were that clueless and naïve, perhaps having seen examples of lavender marriages. Or if perhaps, they were quite aware and trying to give hints to any potential homosexual readers of their textbook what they needed to do to succeed in a homophobic society. Or the third option, that they were both aware and homophobic, insisting that homosexuals live a lie, to live as close as possible to a heteronormative lifestyle trying to “cure” their “maladjusted” sexuality.
This textbook, likely written in the late 1940s or early ’50s, was what my mother had studied and informed her view of homosexuality and what they should do. Thus, it was no wonder that she should be so homophobic and hateful to me as I grew up as that “effeminate” person that was only good for marrying that “mannish” woman.
With the way political winds are blowing lately… I have to wonder if stories like that above will be with us again?
Further Reading:
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Jumping On The MRI Sex vs Gender Bandwagon
Imagine a study that claims to research Sex vs. Gender brain function in children but has zero transkids, no gender dysphoric kids, just average, typical kids. Then researchers hold a press conference where they are called out for this silly claim by reporters who have already heard from other scientists that their claims are bogus. Their defense? That gender is a continuum and they didn’t need transkids in the study.
This is the case for the paper that just came out a few days ago, “Functional brain networks are associated with both sex and gender in children”. So, if they didn’t compare transkids, gender dysphoric kids, what did they compare? They literally used self and parent report on how gender TYPICAL these kids were. Of course, nearly all were typical, with only a slight spread in the data as one would expect (noise + common variation in personality). From that they made the claim that they could, with MRI data and Machine Learning models, see structural differences based on “gender” vs. sex. But what they really found is that there is a large overlap, given that these children were in fact all fairly gender typical and not gender dysphoric.
Given the subjects were all just typical boys and girls and the known NORMAL variation in personality and temperament found in such children, I consider what they discovered to be unrelated to gender dysphoria. I suspect this is just another example of a garbage study by a group with interest in brain network imaging but zero background in gender dysphoria, as their publication history shows. Another hint is the huge number of references for brain imaging studies and only a smattering of gender dysphoria references of the “over-view” kind, with no references to the brain structure research of transsexuals. One gets the impression that they read just enough of the modern literature to use the jargon.
As the paper is available online and not behind a paywall, I won’t try to cover the data presented. Frankly, I consider it to be nearly useless save for showing that there are sex (not gender) differences in the brains of non-gender dysphoric children.
Sadly, most of the science press is buying into their bogus claims uncritically.
Further Reading:
Maching Learning Transsexual Brains = Garbage In: Garbage Out
Further External Reading:
Reference:
Elvisha Dhamala et al., “Functional brain networks are associated with both sex and gender in children.” Sci. Adv.10,eadn4202(2024).DOI:10.1126/sciadv.adn4202
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A Deeper Dive: Trans Teens Are Heterogeneous Group
A couple days ago, I posted an essay on several studies that demonstrated that transsexual teens are not all the same and that younger presenters were not the same as older presenters. In this essay, I wish to take a deeper dive on one of the differences, that of pre-pubertal gender atypicality.
Although the data showed a clear bimodal distribution with high peaks and a low trough, that does not mean that the trough is a hard and fast divisor between two non-overlapping taxonic groups. In fact, the two groups probably DO overlap. The data regarding Recalled Gender Atypicality supports this hypothesis. the natal male data, on a scale of 1 to 5 (low means atypical – high means typical) was a mean of 2.07 (SD=0.5) for the younger presenters and 2.65 (SD=0.72) for the older presenters. Doing a bit more math shows that the difference between these two distributions is Cohen’s d=0.97, a very significant difference, but with 63% overlap (assuming both age groups would have a single modal distribution, which I doubt). Indeed, looking at the ranges for each, 1.13 – 3.67 for the younger presenters and 1.11 – 4.38 for the older presenters, suggests that some prototypical “younger” presenters were over age 14 when they presented at the clinic, and visa versa. With at least one of the “older” presenters having scored at 4.38, just below the max possible score of 5, the “older” presenters decidedly include some very gender TYPICAL boys.
Looking at the natal female data, we see a bit different story: 1.85 (SD=0.42) and 2.15 (SD=0.58), Cohen’s d=0.59 a bit more overlap with ranges of 1.06 – 3.88 and 1.18 – 4.20 showing that both age groups have both quite gender atypical and the older presenters some quite gender typical girls.
Still, the age of presentation to a MODERN clinic does show a trend in that gender typical individuals tend to present later, as older teens.
I got curious as to the instrument used and what score I might get on it, so I found it online and downloaded it. The authors of the paper ignored several items relating to how well or not one got along with family members, knowing it has no real bearing on gender atypicality. My score is 1.26 making me very gender atypical as a child.
Further Reading:
Adolescent Trans Youth Are NOT All The Same
References:
Arnoldussen, M., de Rooy, F. B. B., de Vries, A. L. C., van der Miesen, A. I. R., Popma, A., & Steensma, T. D. (2023). Demographics and gender-related measures in younger and older adolescents presenting to a gender service. European Child and Adolescent Psychiatry, 32, 2537–2546. https://doi.org/10.1007/s00787-022-02082-8
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Adolescent Trans Youth Are NOT All The Same
In a paper that just published “open access” (not behind a paywall) today from the Netherlands clinicians explored the long known fact that “early onset” transsexuals were not the same as “late onset” transsexuals, but looking only at those who presented at their clinic as youth (<19 y/o). In the past, the definition of “early” vs. “late” was set at the age of gender dysphoria onset, typically with a dividing line at puberty, given that autogynephilic desire and its consequent gender dysphoria often developed post puberty. Typically, this was only applied to natal male subjects. But in this paper, they use it for both natal sexes. As the data they gathered showed, this does make sense to do so. For solid operational definition purposes and to avoid self-report bias, they use the age of clinical presentation as their cut-off between the two, labeling them “younger” and “older” presenters.
Perhaps not surprisingly, using a cut-off at age 14 made total sense, not just for classic etiological reasons, but given that when their ages of presentation were plotted, the subjects showed a clear and distinct bimodal age distribution as this histogram shows. The distribution shows modal peaks at ages eleven and sixteen with a trough at age 13. The data clearly shows that there are two populations, from two etiological taxons. As well as age difference at presentation, there are differences in mental health, autistic traits, and pre-pubertal gender atypicality.
“The sample consisted of significantly more AFAB than AMAB, with 58.9% of younger presenters and 70.2% of older presenters AFAB. Moreover, significantly more younger than older presenters lived with both biological parents, were diagnosed with gender dysphoria, and started with medical treatment. … A recent study at the CEGD found as well that older presenters had less recalled gender nonconformity in childhood compared to younger presenters.”
The older presenters were twice as likely to NOT have been diagnosed as gender dysphoric upon assessment and almost twice as likely not to be prescribed medical gender affirming care at 25%.
Another unsurprising finding is that the older presenters are more likely to have mental health and behavioral problems. Another unsurprising bit of data was that the older natal males were twice as likely to have clinically significant autistic traits as younger natal males, which had the lowest, as the authors state,
“The aim of this study was to examine if mental health differences exist between younger and older presenting adolescents attending our gender identity service in Amsterdam. Overall, we found that younger presenters had fewer psychological problems and autistic traits compared to older presenters.”
It is unfortunate that this paper did not examine the subjects sexual orientation and autogynephilia/autoandrophilia.
Today’s paper was NOT the first to look at the differences between younger and older presenting youth, Sorbara, et al. (2020) found the same trend of increased mental health issues in older presenting youth. They used the age of fifteen (15 y/o) as their cut off based on the desire to ensure that all of the older subjects were post-puberty onset. Earlier, Sorbara looked at the possible reasons for the differences in timing of seeking clinical help. Two factors stood out 1) differential age of “first recognition” 2) differential pre-pubertal gender atypicality,
“Youth and caregivers described looking to the youth’s gender expression to interpret and evaluate gender incongruence. Younger-presenting youth and caregivers recalled expression of the identified gender in childhood, prompting subsequent feelings of expectedness and acceptance. Conversely, more caregivers of older-presenting youth described a lack of indication of gender incongruence in childhood and inconsistencies in gender expression after coming out. Some of these caregivers expressed concern that their child’s transgender identity was externally motivated.”
Some quotes from the caregivers are insightful and very reminescent of those classically described by parents of “early transitioners” vs. “late transitioners” in studies done decades ago, before transkids were able to get help at clinics. From a parent of an “older presenter”,
“OlderC of AFAB youth: I didn’t see any…I don’t know, there [were] no signs… there was nothing really when she was growing up, right? I was really close to her and you know we had a good father-daughter relationship and… never, never once was it mentioned or hinted or, or any sign or anything ‘till, like I said, 12, 13 maybe…”
Compared that to a “younger presenter”,
“YoungerC of AFAB youth: I was not surprised at all. I birthed 4 girls, and so having the 3 older female siblings, I could see the difference in [my child] right from the very beginning, well, I would say probably from 2 or 3 years old. It did not come as a surprise to me at all when he told me. “
Just for comparison, grins and giggles, compare the above to what my mother said to Dr. Fisk when I was evaluated at age 17 in 1975 (after having been sent to “conversion therapy” at age 10 and at age 16),
“I have known for years that he wanted to be a girl. But I thought that was [morally] wrong. He was very different than his brothers. All their friends were boys. His were always girls,” naming several of my friends over the years, starting with my pre-school friends, but couldn’t remember my friend who had been my only guest on my tenth birthday. “Marian,” I interjected for the only time during the whole interview. “He was always very prissy. He would walk clear around even the shallowest puddles. When he was little, I would put him in clean clothes on Monday and on Friday they would still be clean.”
So, we can see that just as there are differences in populations that transition young and in mid-life, with increasing mental health issues in older presenting & transitioners, we also see that same difference in today’s young people, with those presenting and transitioning in their early years compared to older teens. It is as if the “transgender” umbrella of adults of the past were time compressed into the teen years of today. None of the results are surprising to those that know the field.
Addendum 7/9/2024 late afternoon:
In a related paper Arnoldussen, et. al. had additional data on the same cohort as the de Rooy paper discussed above. Most particularly, they presented a finer grained age histogram that showed that the bimodal distribution had peaks at ages 11 and closer to 17, rather than at age 16 and the trough just under age 14.
Even more interesting is that they also provide histograms broken out by natal sex. In this, one can see that for natal females, the ages between 16 and 18 dominate.
Addendum 3/22/2025: A paper from 2022 by Turban, et al, has data that on casual reading was meant to indicate that younger one can access gender affirming hormones (puberty blockers and cross-sex hormones = HRT), the better the psychological outcome for gender dysphoric people. However, in light of the data from the other papers I have cited here, the data supports quite a different interpretation. Always look at the DATA and fit that data to other papers to make sense of it. It is NOT about gaining access sooner, but that there is a taxonic difference between those who present at clinics for such medical care at different ages. The data is very much in keeping with the observation that early onset transsexuals have fewer co-morbid mental health issues than late onset transsexuals.
The data was gathered in the 2015 via a community survey, which may not be as accurate as clinical data, but when compared to the clinical data, looks to be in general agreement, as explained in the paper,
We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional non-probability sample of 27,715 transgender adults in the U.S. Using multivariable logistic regression adjusting for potential confounders, we examined associations between access to GAH during early adolescence (age 14–15), late adolescence (age 16–17), or adulthood (age ≥18) and adult mental health outcomes, with participants who desired but never accessed GAH as the reference group. 21,598 participants (77.9%) reported ever desiring GAH. Of these, 8,860 (41.0%) never accessed GAH, 119 (0.6%) accessed GAH in early adolescence, 362 (1.7%) accessed GAH in late adolescence, and 12,257 (56.8%) accessed GAH in adulthood. After adjusting for potential confounders, accessing GAH during early adolescence, late adolescence, or adulthood was associated with lower odds of past-year suicidal ideation when compared to desiring but never accessing GAH. In post hoc analyses, access to GAH during adolescence (ages 14–17) was associated with lower odds of past-year suicidal ideation when compared to accessing GAH during adulthood.
As explained in a Stanford University PR puff piece,
“Compared with members of the control group, participants who underwent hormone treatment had lower odds of experiencing severe psychological distress during the previous month and lower odds of suicidal ideation in the previous year. Odds of severe psychological distress were reduced by 222%, 153% and 81% for those who began hormones in early adolescence, late adolescence and adulthood, respectively. Odds of previous-year suicidal ideation were 135% lower in people who began hormones in early adolescence, 62% lower in those who began in late adolescence and 21% lower in those who began as adults, compared with the control group.”
The “control group” was those who said that they wanted to use HRT, but never did. This group is likely “marginal transvestites”, autogynephilic cross-dressers who dreamed of transitioning, but had not done so. As has been documented for decades, “early onset” (also known as “Homosexual Transsexuals” – HSTS) are far more emotional stable regardless of what age they transition, but typically do so significantly younger than “late onset” (AGP/AAP) transsexuals). This paper adds to the data that shows that the two types not only segregate by age of transition, teens vs. adult, but now also by age of clinical presentation as teens, early adolescence verses late adolescence.
Further Reading:
Essay on age of gender dysphoria onset vs. sexual orientation
Essay on bimodal distribution on age of gender dysphoria onset and transition in transwomen
References:
de Rooy, F.B.B., Arnoldussen, M., van der Miesen, A.I.R. et al. Mental Health Evaluation of Younger and Older Adolescents Referred to the Center of Expertise on Gender Dysphoria in Amsterdam, The Netherlands. Arch Sex Behav (2024). https://doi.org/10.1007/s10508-024-02940-3
Sorbara, J. C., Chiniara, L. N., Thompson, S., & Palmert, M. R. (2020). Mental health and timing of gender-affirming care. Pediatrics, 146. https://doi.org/10.1542/peds.2019-3600
Sorbara, J. C., Ngo, H. L., & Palmert, M. R. (2021). Factors associated with age of presentation to gender-affirming medical care. Pediatrics, 145. https://doi.org/10.1542/peds.2020-026674
Arnoldussen, M., de Rooy, F. B. B., de Vries, A. L. C., van der Miesen, A. I. R., Popma, A., & Steensma, T. D. (2023). Demographics and gender-related measures in younger and older adolescents presenting to a gender service. European Child and Adolescent Psychiatry, 32, 2537–2546. https://doi.org/10.1007/s00787-022-02082-8
Turban, Jack L., et al. “Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.” PLos one 17.1 (2022): e0261039.
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Hearing (Trans) Zebra Hoofbeats
“When you hear hoofbeats, think of horses, not zebras.” — Dr Theodore Woodward
I’ve written about Case and Ramachandran before and how Ramachandran tries to explain transsexuality and gender dysphoria in terms of altered neurological structures, hypothesis with very little support using evidence that has far more mundane and compelling explanations with far more consilient support. The paper I’m writing about here is a little over a decade old, but like his other papers, suffers from the same weaknesses.
In their 2012 paper, they attempt to explain “Bi-Gendered” people using the metaphoric sound of zebra hoofbeats. Perhaps they can be forgiven this because of their ignorance of the cross-dressing community and of how autogynephilia presents in it. Here is how they view it,
” “Bigender” is a recently formed sub-category of transgenderism, describing individuals who experience a blending or alternation of gender states. … These observations suggest a biologic basis of bigenderism and lead us to propose a novel gender condition, “alternating gender incongruity” (AGI). We hypothesize that AGI may be related to an unusual degree or depth of hemispheric switching and corresponding callosal suppression of sex appropriate body maps in parietal cortex- possibly the superior parietal lobule- and its reciprocal connections with the insula and hypothalamus.”
First off, “Bigender” is NOT “a recently formed sub-category of transgenderism”. In fact, the term has been in active use for as long as the term “transgender” has been, at least since the 1960s. It was in use by the very same people and for the very same reason. Both terms were used by life-style cross-dressers, autogynephilic heterosexual men who attempted to describe their interest in, indeed, obsession with, erotic cross-dressing as not actually being erotic, but as merely “exploring their feminine side”. They even expressed that misdirection in the name of one of their more popular social clubs called the “Society for the Second Self” or “Tri-S”.
The authors seem to be much impressed with the notion that these individuals actually experience two gender identities. But, knowing who these people are from decades of social interaction and candid conversations, this is simply not the case. What they have is two personas, one for everyday life as their natal sex, and one for when they are cross-dressed. They weren’t born with it. They put a lot of work into developing and enacting it. One aspect of autogynephilic experience is that when cross-dressed, they are sexually aroused to some degree. Should a cross-dresser achieve orgasm while cross-dressed, that arousal disappears and it is common for them to very suddenly revert to feeling uncomfortable being cross-dressed. Another well known aspect is that autogynephilia competes with gynephilia. This can lead to a sudden and unwanted “flip” from autogynephilic “feeling girly” back to the uncomplicated gynephilia in a given social situation with an attractive woman present and now feeling uncomfortable dressing “en femme” and wishing to present and flirt as a man with that woman.
The paper was written in 2012, which interestingly, is about the time that the “non-binary” fad in natal females took off. I’ve already shown that non-binary women are NOT gender atypical nor gender dysphoric, and how they developed the term in response to the term “bi-gender” in prior use by cross-dressers.
The authors also mention increased non-right handedness among the ‘bi-gendered’. But they fail to note that that is also true of autogynephilic transwomen. Yes, something neurologically interesting is happening in this population, both fully gender dysphoric and part-time cross-dressers (recall that this is both a spectrum and a progression). But it is NOT some silly switching from using one hemisphere to the other as Case and Ramachandran argue.
Let’s not jump to the conclusion that one is hearing zebras when we know there are horses around.
Further Reading:
Brain Maps… Or Searching for The Lost Continent of Atlantis
And Things That Go Bump in the Night
Is The Non-Binary Fad Ready to Fade?
Reference:
Laura K. Case, Vilayanur S. Ramachandran, “Alternating gender incongruity: A new neuropsychiatric syndrome providing insight into the dynamic plasticity of brain-sex” Medical Hypotheses, Volume 78, Issue 5, (2012),
https://doi.org/10.1016/j.mehy.2012.01.041
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Transsexual Youth Thrown Under The Bus – Again
When I was deeply involved in transactivism in the ’80 and ’90s, and researching and teaching transhistory, I saw first hand how many times transsexuals were thrown under the political bus by gays and lesbians and the organizations that they led. But in the past twenty years, I’ve seen how transsexuals have thrown other transsexuals under that very same bus.
But, the story is just a bit more complicated. Those throwing others under the bus are NOT in the same etiological taxon and thus often do not feel the same “us” tribal loyalty. I speak of course of the vast real differences between MTF/FtM “early onset”/”homosexual transsexuals” vs. MTF “late onset/”autogynephilic transsexuals”. We have seen a number of “late transitioners” literally selling transkids down the river, failing to support them, and failing to recognize and honor the different needs of HSTS (of both natal sexes) vs. AGP transwomen. They have very often denied the etiological difference and have falsely spoken for and over transkids (and former, now adult, transkids). Because of this, some, not the majority, but some, also fail to feel empathy and compassion for transkids and have been willing to espouse the ugly idea that transkids should not be allowed to transition, instead to be required to live as they did, waiting until mid-life before social and medical transition. But most of the time that they have done this, they didn’t have all that much power to harm transkids en mass.
This past week that changed. As has been reported in the media, the Biden Administration (Presidential Executive office of the United States) put out a statement which has been correctly portrayed as a “betrayal” of transsexual youth and by extension, due to how it can be used as part of step by step campaign to remove transsexual rights for even adults, all transsexuals, that they support limiting gender affirming care to adults only save for “mental health services”, and specifically called out that surgical care be limited to adults only. This raises the question of how this came about. How could the Biden Administration which had previously been so supportive of the LGBT communities, suddenly turn on transsexual youth like this.
Erin Reed touches on it, but does not dive deep enough into the issue,
“The reaction of the transgender state legislators follows news that broke on June 27 when the administration informed Fox News that “the administration does not support surgery for minors,” and reiterated that statement to The New York Times. These statements responded to a New York Times article asserting that Admiral Levine was pressuring the World Professional Association for Transgender Health to remove age limits for transgender surgeries, seemingly implying that Levine favored surgeries for very young youth. In reality, Levine opposed lowering age limits, favoring a more conservative approach that maintained the age at 18+… On Tuesday of last week, the White House issued a follow-up statement that many LGBTQ+ activists decried as worse than the original: “These are deeply personal decisions and we believe these surgeries should be limited to adults. We continue to support gender-affirming care for minors like mental health care and respect the role of parents, families, and doctors in these decisions.”
These statements read like they were written by anti-transkid activist focused on limiting medical care for transkids to ‘conversion’ or ‘exploratory therapy’ instead of gender affirming care.
Rachel Levine is currently an assistant secretary for health in the Biden Administration. She is also transsexual. She is a “late transitioner” having socially transition in 2011 at the age of 53. (For comparison, I am almost the same age, older by only a few months, but I began social transition in 1975 at the age of 17.) She was married to a woman for 25 years, siring two children, who knew her as “Dad”. (Again for comparison, I’ve been married to a man for 25 years and foster/adopted two children who always knew me as “Mom”.) Thus, Levine has no experience of being a transkid. She has no real idea what transkids are really like and what transkids really need, though she has claimed that she does.
The Biden Administration would surely have consulted Levine, their top transsexual health care advisor before putting out an announcement regarding transsexual health care needs. I can’t but believe that her lack of real understanding of, and lack of empathy for, transkids needs was part of the reason this became such a shit show.
I am heartened that there had been a strong response from both transsexual and general LGBT activist organizations. The Human Rights Campaign said in a statement,
“The Biden administration is flat wrong on this. It’s wrong on the science and substance. These decisions belong between a patient, their family, and their health care provider. This administration has committed to fighting for trans youth and must continue without hesitation.”
Let us hope that the Biden Administration realizes their error and retracts this mistake.
Further Reading:
Historic Transphobia In The Gay And Lesbian Communities
Further External Reading:
Why Transgender People Are Not Feeling Gavin Newsom
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A Critical Response to the Cass Review from Yale
I highly recommend those committed to good science and medical care for transsexual youth to read for themselves the 39 page response from people who are FAR better experts on the topic of pediatric gender affirming care than the bigots that were part of the Cass Review.
However, I do have some comments about this response.
When I saw who wrote it I was both encouraged and dismayed. Among the authors is Johanna Olson-Kennedy, MD, Professor of Clinical Pediatrics, Keck School of Medicine of University of Southern California. I deeply respect her work and trust her scientific judgment. But also among the authors is Jack Turban, MD, MHS, Assistant Professor of Psychiatry & Behavioral Sciences and Affiliate Faculty at the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco who I have noted in the past, in these very same essay pages, to have used invalid survey data of young people to make bold, but erroneous claims as the incidence rate of “trans” teenagers. When I saw his name, I made a silent prediction, a bet with myself, that this response paper would also include such. I was not disappointed.
In a previous paper, Turban used data from two surveys, uncritically accepting that they were valid and correct, that purported to show that between 1.6% and 2.4% of teens in the United States are “trans” and thus gender dysphoric. As I’ve shown, these numbers show only the invalidity of using such survey instruments as it is both too easy to simply check off the box “yes” to the question “are you trans”, with no clear operational definition of what that means. We know from proper research that the number of gender dysphoric individuals who have socially transitioned, and thus can properly be called ‘transsexual’ is a tiny minority on the order of one in 10,000 (0.01%) and that includes both etiological types, young transitioning “early onset” and mid-life adult transitioning “late onset”. But the Yale response uses what they call a “conservative estimate” of the number of untreated transsexual teens as ten times that number at 0.1%, again using invalid survey data. Using invalid data to make the claim that transkids are being egregiously under treated in the United Kingdom serves only to weaken the validity and scientific strength of the response.
In a similar vein, Turban has used invalid survey data and then tortured logic to argue that there is no “social contagion”, as a response to the notion of “exponential” increase in the number of teens seeking gender affirming medical care. Turban is seemingly obtuse regarding the large increase in teens falsely claiming to be “trans” and more recently “non-binary”. This fad is indeed a social contagion, as all fads are. But it is not indicative of a dramatic increase in clinically valid gender dysphoria. In other words, people have been talking past each other about two different phenomena.
Overall, the response is excellent and worth reading and citing to counter misuse and misplaced trust in the Cass Review.
Addendum 5/13/2015: A new peer reviewed paper out of a UK journal just came out that showed that the Cass Review was both flawed and biased, with unsupported claims, and should NOT be used to set medical care policy.
Further Reading:
How Many Trans Folk Are There, Really?
Is The Non-Binary Fad Ready To Fade?
Falsely Claiming To Be Trans Is Cool (NOT!)
References:
Turban, et al., “Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents In The United States”, Pediatrics (2022), https://doi.org/10.1542/peds.2022-056567
Noone, C., Southgate, A., Ashman, A. et al. Critically appraising the cass report: methodological flaws and unsupported claims. BMC Med Res Methodol 25, 128 (2025). https://doi.org/10.1186/s12874-025-02581-7
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On the Science of Changing Sex 
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